Transcript Document

The Satisfying Solution for You and Your Partner
October 6, 2009
BELLEVUE UROLOGY PRESENTS:
Men’s Health Talk
Effective Treatment Solutions for
BPH, Urinary Incontinence and
Erectile Dysfunction
The Satisfying Solution for You and Your Partner
Tonight's Agenda
Urologists from Bellevue Urology will present information on BPH,
urinary incontinence, and ED, its causes and treatments
Galen & Linda Bird, patient advocates will share their story of their
struggle with ED & urinary incontinence.
Question & Answer session
Appointment cards are available for you to make an appointment
tonight
The Satisfying Solution for You and Your Partner
Benign Prostatic
Obstruction
• Replaces the term Benign Prostatic
• Hypertrophy ( B.P.H. ) which is a histological
description of pathological tissue.
• Represents the most common etiology of
• Bladder Outlet Obstruction ( B.O.O. )
• Bladder Outlet Obstruction represents one
etiology of Lower Urinary Tract Symptoms
• ( L.U.T.S. )
The Satisfying Solution for You and Your Partner
Lower Urinary Tract
Symptoms
•
•
•
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Storage Symptoms
Voiding Symptoms
Bladder Sensation Symptoms
Postmicturition Symptoms
The Satisfying Solution for You and Your Partner
Storage Symptoms
Increased Daytime Frequency
Nocturia
OVERACTIVE
Urgency
BLADDER
Urinary Incontinence - Urge Incontinence –Stress
Incontinence - Mixed Incontinence - Enuresis –
Continuous Urinary Incontinence
The Satisfying Solution for You and Your Partner
Voiding Symptoms
•
•
•
•
•
•
Urinary Hesitancy
Straining to Void
Slow Urinary Stream
Intermittent Stream
Terminal Dribbling
Splitting or Spraying of the Urinary Stream
The Satisfying Solution for You and Your Partner
Lower Urinary Tract
Symptoms
Most Common Symptoms were all of the Voiding Type
Most Bothersome Symptoms were of the Storage Type
Not all symptoms are Bothersome
The Satisfying Solution for You and Your Partner
Lower Urinary Tract
Symptoms
The coexistence of Benign Prostatic Enlargement
and Bladder Outlet Obstruction can be termed
Benign Prostatic Obstruction
The Satisfying Solution for You and Your Partner
Lower Urinary Tract
Symptoms
• Not all voiding symptoms are related to
obstruction
• Bladder Outlet Obstruction may be a component
of
• L.U.T.S.
• Benign Prostatic Enlargement is one form of
• Bladder Outlet Obstruction
• B.P.H. is a Histological Dx.
The Satisfying Solution for You and Your Partner
The Satisfying Solution for You and Your Partner
The Satisfying Solution for You and Your Partner
The Satisfying Solution for You and Your Partner
L.U.T.S. caused by Benign
Prostatic Obstruction
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Need to document that BPO is the cause of
Bladder Outlet Obstruction (B.O.O.)
History
Physical Examination
Routine Labs and Studies
Specialist Investigations
The Satisfying Solution for You and Your Partner
LUTS- History
• AUA or International Symptom Score
• Voiding Diary / Frequency Volume Chart
• Medical History
The Satisfying Solution for You and Your Partner
The Satisfying Solution for You and Your Partner
LUTS - Physical Exam
• Palpation of the Abdomen
• Examination of the Genitalia ( note any meatal
stenosis )
• Digital Rectal Exam to note size, contour,
consistency, and symmetry of the Prostate. Rule
out any rectal mass
• Focused neurological examination
The Satisfying Solution for You and Your Partner
LUTS/ Bladder Outlet
Obstruction- Lab
• Urinalysis
• Creatinine
• PSA
The Satisfying Solution for You and Your Partner
LUTS/Bladder Outlet
Obstruction- Therapy
• Moderate/ Severe Symptom Score. Low Bother
Score, Negligible Post Void Residual• Expectant Therapy
• Moderate/ Severe Symptom Score. Low Bother
Score- Significant Post Void Residual- Alpha
• Blocker Therapy
• Moderate/ Severe Symptom Score. High Bother
Score/ Negligible or Significant Post Void
• Residual- Alpha Blocker Therapy or Intervention
( Thermal Therapy or TURP )
The Satisfying Solution for You and Your Partner
Goals of Therapy for BPH
Successful treatment of BPH is measured by:
• Decreased symptoms (IPSS/AUA)
• Decreased bother (bother score) and interference with
• daily activities
• Decrease in prostate size or arrest of further growth
• Increase in peak flow rate
• Improvement in obstruction
• Prevention of long-term outcomes/complications
• Acceptable adverse events profile
US Agency for Health Care Policy and Research. AHCPR publication 94-0582; O’Leary MP. Urology. 2000;56(suppl 5A):7-11.
The Satisfying Solution for You and Your Partner
Treatment Options
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Watchful waiting
Medical therapy
Phytotherapy
Pharmacologic therapy
• Alpha-adrenergic blockers
• 5-Alpha-reductase inhibitors
• Anti-muscarinic/AntiCholinergic medications
• Combination therapy
• Minimally invasive surgery
• TUMT
• TUNA
• Less invasive surgery
• VLAP
• ILC
• TUVP
• Major surgery
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TURP (gold standard)
TUIP
PVP ‘Green Light Laser’
Open surgery
(prostatectomy)
Chatelain C et al. In: Chatelain C et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health Publication Ltd; 2001;519-534; DeBruyne
FMJ et al. In: Chatelain C et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health Publication Ltd; 2001;397-421; AUA Practice
Guidelines Committee. J Urol. 2003;170(2):530-547.
The Satisfying Solution for You and Your Partner
5 Alpha - reductase
inhibitors
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Appropriate and effective treatment for patients with
LUTS associated with demonstrable prostatic
enlargement *
Not appropriate for men with LUTS who do not have
prostatic enlargement *
May prevent progression of disease
Currently represented by finasteride and dutasteride
*AUA Guideline on BPH
The Satisfying Solution for You and Your Partner
The Satisfying Solution for You and Your Partner
The Satisfying Solution for You and Your Partner
Alpha - adrenergic blocker
therapy
• Appropriate treatment options for patients with
LUTS secondary to BPH*
• Currently represented by Alfuzosin, Doxazosin,
Tamsulosin, and Terazosin *AUA Guidelines for
• BPH
The Satisfying Solution for You and Your Partner
Combination Medical
Therapy
The combination of an alpha – adrenergic
receptor blocker and a 5 alpha reductase
inhibitor ( combination therapy ) is an
appropriate and effective treatment for patients
with LUTS associated with demonstrable
prostatic enlargement *
* AUA Guidelines on the management of BPH
The Satisfying Solution for You and Your Partner
What is ED?
The inability to maintain an erection firm
enough to have sexual intercourse
The Satisfying Solution for You and Your Partner
How Common is It?
• 1 in 10 men
• Over 30 million American men
• 90% physical, 10% psychological
Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of
the Massachusetts male aging study. J Urol Jan 1994; 151: 54-61.
Sun P, Seftel A, Swindle R, Ye W, Pohl G. The costs of caring for erectile dysfunction in a managed care setting: evidence from a large
national claims database. J Urol Nov 2005; 174: 1948-1952.
Mulligan T, Teitelman J. Geriatric Sexual dysfunction. VA Med Q Apr/Jun 1991; 118(2): 97-9.
The Satisfying Solution for You and Your Partner
Physical Causes of ED
• Diabetes
• Heart disease
• Surgery (Prostate, Bladder, Colon, Rectal)
• Medications
• Spinal injury
• Hormone imbalance
The Satisfying Solution for You and Your Partner
Do I Have To Live With ED?
NO!
• Nearly every man can be successfully treated
The Satisfying Solution for You and Your Partner
Treatment Options
Oral Medications
(Viagra®, Levitra®, Cialis®)
Vacuum Erection Devices
Injection Therapy
Urethral Suppositories
Penile Implants
Viagra is a trademark of Pfizer Inc., Levitra is a trademark of Bayer and GlaxoSmithKline and Cialis is a trademark of Lilly ICOS.
The Satisfying Solution for You and Your Partner
Oral Therapies:
• Work only in response to sexual stimulation
• Must take Viagra and Levitra at least ½ hour
before anticipated sexual activity. They
remains effective for up to 4 hours after are
they taken
• Cialis can last as long as 36 hours
The Satisfying Solution for You and Your Partner
Vacuum Erection Devices
The Satisfying Solution for You and Your Partner
Vacuum Erection Device:
• Externally applied device mechanically
increases penile blood engorgement
• Cylinder/pump placed over penis creates
closed chamber; pump creates vacuum,
drawing blood into corpora cavernosa
•Constrictive elastic ring then placed at
base of penis to restrict flow of suctioned
blood
Levine LA, Dimitriou RJ. Urol Clin North Am. 2001;28:335-341.
Montague DK, et al, for the AUA Clinical Guidelines Panel on Erectile Dysfunction. J Urol. 1996;156:2007-2011.
The Satisfying Solution for You and Your Partner
Vacuum Erection Devices
Advantages
Not a medication
Minimally invasive
Disadvantages
Discomfort
35% Satisfaction Rate
The Satisfying Solution for You and Your Partner
Urethral Suppositories
MUSE (Prostaglandin E1)
Small medicated pellet placed in the tip of the penis
Advantages
Relatively easy
Fast
Disadvantages
30-65% effective
Side effects include pain
The Satisfying Solution for You and Your Partner
Transurethral Medication:
MUSE
The Satisfying Solution for You and Your Partner
Injection Therapy
• Diabetic needle and syringe
• 5-15 minute response time
• 30 minute to 2 hour duration
Possible side effects
Pain on administration
Prolonged erections
Scarring
The Satisfying Solution for You and Your Partner
Injection Therapies
Single agent and mixed agents
Direct injection of medication into the penis
Advantages
Fast
Minimally invasive
Disadvantages
61-73% Effective
Side effects
Needles
The Satisfying Solution for You and Your Partner
Some Are More Satisfying
Than Others
Oral Medications: not effective in 30% of cases1
Vacuum Erection Devices: cumbersome, unromantic
Injection Therapy: needles, expensive, may cause burning
sensation, long term scarring
Urethral Suppositories: expensive, may cause burning
sensation
1 Goldstein
I, Lue TF, Padma-Nathan H, Rosen RC, Steers WD, Wicker PA; Sildenafil Study Group. Oral sildenafil in the treatment of erectile
dysfunction. 1998. J Urol. 2002 Feb;167(2 Pt 2):1197-203; discussion 1204
The Satisfying Solution for You and Your Partner
Penile Implants vs.
Other Treatment Options
Overall Patient Satisfaction with ED Treatments1
0%
20%
40%
60%
Penile
Implant
93%
Oral
Medication
Penile
Injection
80%
51%
40%
Percentage Satisfied
1 Rajpurkar A, Dhabuwala CB. Comparison of satisfaction rates and erectile function in patients treated with sildenafil, intracavernous prostaglandin E1
and penile implant surgery for erectile dysfunction in urology practice. J Urol Jul 2003 v.170(1)p.159-63.
100%
The Satisfying Solution for You and Your Partner
Penile Implants
Ideal for men who have tried other
treatments without success
• On the market for over 30 years
• 25,000 penile implants per year
• Over 300,000 implants to date
• High patient and partner satisfaction
The Satisfying Solution for You and Your Partner
Types of Penile Implants
One-piece non-inflatable
Two-piece inflatable
Three-piece inflatable
The Satisfying Solution for You and Your Partner
One - Piece Non-Inflatable
Penile Implant
Advantages
Disadvantages
Easy for you or your partner to activate
Stays firm when not in erect
position
Good option for men with
limited dexterity
Totally concealed in body
The simplest surgical procedure
Least expensive prosthesis
May “show” through clothing
The Satisfying Solution for You and Your Partner
Two – Piece Inflatable
Penile Implant
Advantages
Disadvantages
Simple to use
Requires some manual dexterity
Fast and simple one-step
deflation
Possibility of leakage or
malfunction
Totally concealed in body
Flaccidity not as natural
appearing as the 3-piece
Natural flaccidity compared to
non-inflatable implants
The Satisfying Solution for You and Your Partner
Three – Piece Inflatable
Penile Implant
Advantages: same advantages as
the two - piece plus
Disadvantages
Acts and feels more like a
natural erection
Possibility of leakage or
malfunction
Expands the girth of the penis
Possibility of unintentional
erections
More firm and full than other implants
Feels softer and more flaccid when
deflated
Requires some manual dexterity
The Satisfying Solution for You and Your Partner
Proven Benefits
• Achieve an erection easily and maintain it
• Erection hard enough for penetration and allows you
to complete sexual intercourse
• Feels natural to you and your partner
• Easy to use
• Dependable, works every time
• Usually outpatient procedure
The Satisfying Solution for You and Your Partner
In addition, penile implants
• Requires surgery
• Risk of surgical complications which may include infection
• Cost may be prohibitive
• Possible discomfort or pain from use
• Non-reversible
• In rare cases, there may be mechanical failures which
may require revision surgery
The Satisfying Solution for You and Your Partner
Implants are Highly
Recommended
100%
95%
90%
85%
80%
92%
would
recommend
to others3
90%
partners
would
recommend
to other
couples4
Levine LA, Estrada CR, Morgentaler A. Mechanical reliability
and safety of, and patient satisfaction with the Ambicor
inflatable penile prosthesis; results of a 2 center study. J Urol.
2001 Sep; 166 (3) :932-7
The Satisfying Solution for You and Your Partner
Summary
• ED is a common problem
• Nearly every man can be successfully treated
• Penile implants offer a dependable, long-term solution
• Talk to your partner, talk to your Urologist
The Satisfying Solution for You and Your Partner
Incontinence is another
problem that affects
some ED patients.
The Satisfying Solution for You and Your Partner
What is urinary incontinence?
“The objective demonstration
of involuntary loss of urine consequent to
bladder and/or sphincter dysfunction.”
The International Continence Society
Ballanger P et al. Female Urinary Incontinence. Eur Urol 1999; 36:165-174.
The Satisfying Solution for You and Your Partner
What is urinary incontinence?
“My plumbing has a faulty washer”
The Satisfying Solution for You and Your Partner
Types of incontinence
Stress Incontinence
Leakage during physical activity that increases
intraabdominal pressure, i.e. lifting, exercising,
sneezing, and coughing
Urge Incontinence
Leakage associated with an overwhelming need
to urinate Gotta go, gotta go!
Mixed Incontinence
Combination of the above
Hunskaar et al. One hundred and fifty men with urinary incontinence. Scand J Prim Health Care 1993; 11:193-196.
The Satisfying Solution for You and Your Partner
How does the process work?
Bladder collects urine
The sphincter - a
circular muscle at
the level of the
prostate controls
the flow of urine
The sphincter muscle
wraps around the
urethra
A healthy sphincter stays closed until one relaxes it
to urinate
The Satisfying Solution for You and Your Partner
Am I the only one
with incontinence?
NO!
2 million men in the world suffer
from loss of urinary control
Rate of incontinence ranges between 1-31% after
prostate surgery
AMS 2003 Annual Report
Campbell’s Urology 2002 8th Edition
The Satisfying Solution for You and Your Partner
Why treat incontinence?
Avoid negative feelings
embarrassment, discomfort, isolation, anger
and depression
Return to usual lifestyle
Regain dignity
Resume intimacy
Save money on protective garments
Improve quality of life
The Satisfying Solution for You and Your Partner
Why treat incontinence?
150 men reported the practical inconveniences
associated with
incontinence:
52%
37%
17%
12%
11%
Extra Laundry
Smell
Extra Expense
Skin Irritation
Disturbed Sleep
Source: Hunskaar s, Sandvik H. one hundred and fifty men with urinary incontinence.
Scand J Prim Health Care 1993 v. 11 p.193-196
The Satisfying Solution for You and Your Partner
Management options
Pads/diapers
Medication
Devices
The Satisfying Solution for You and Your Partner
Devices
Clamps
Cunningham clamp, C3-clamp
Advantages
• Non-medical, non-surgical
• Easy to use
• Works well
Disadvantages
• Bulky
• Pressure necrosis
• Generally not a turn on
The Satisfying Solution for You and Your Partner
Devices
Catheters
External vs internal
Advantages
• Works
Disadvantages
• Attached to a bag
• Increased risk of
infection
The Satisfying Solution for You and Your Partner
Treatment options
Behavioral modification
Biofeedback
Injectables
Surgery
The Satisfying Solution for You and Your Partner
Behavioral modification
Void frequently
Avoid caffeine, alcohol
Avoid activity that increases
intraabdominal pressure
The Satisfying Solution for You and Your Partner
Pelvic floor rehabilitation
a.k.a. biofeedback
Means of teaching Kegel exercises
Objective way to measuring pelvic
floor strength
? how much better than verbal
instruction
The Satisfying Solution for You and Your Partner
Surgical options for male stress incontinence
AdVance Male Sling
Artificial Urinary Sphincter
The Satisfying Solution for You and Your Partner
AdVance™ Male Sling
Sling restores urethra to its proper anatomical position for optimal
sphincter function, restoring urinary control
• Procedure:
– Spinal or general anesthesia
can be used
– Three small incisions: 1 under the
scrotum, 2 over groin creases
– Specially designed surgical tools
are used to position the sling
– Sling is gently tensioned
– Incision closed
The Satisfying Solution for You and Your Partner
Artificial Urinary Sphincter
(AUS)
over 100,000 implanted since 1972
The Gold Standard for treatment
of moderate to severe
incontinence
60 minute outpatient procedure
92% of patients would have the
device placed again
96% of patients would
recommend it to a friend
Device is placed completely in
the body, providing simple,
discreet control
Litwiller SE, et al. Post-prostatectomy incontinence and the artificial urinary sphincter; a long-term study of
patient satisfaction and criteria for success. J of Urol 1996; 156:1975-1980.
The Satisfying Solution for You and Your Partner
1
2
3
The Satisfying Solution for You and Your Partner
Male Incontinence Severity Level
Guidelines
Onur R, Rajpurkar A, Singla A. New perineal bone-anchored male sling; Lessons learned.
Urology Jul 2004 v. 64 (1) p.58-61
The Satisfying Solution for You and Your Partner
What should you do next?
See your Urologist!
Come prepared with questions
Discuss your treatment options
Your lifestyle and medical
condition are important factors
The Satisfying Solution for You and Your Partner
Summary
Incontinence is a common problem
Nearly every man can be successfully treated
Some treatments are more effective than others
Surgical treatment options offer proven,
long-term solutions
Talk to your Urologist – talk to your partner
For more information on Incontinence, ask for the
patient brochures, “End Urinary Incontinence” and
“The Satisfying Solution”
You can Live
Life Dry!
The Satisfying Solution for You and Your Partner
Galen Bird, DVM
The Satisfying Solution for You and Your Partner
Urinary Incontinence
The Satisfying Solution for You and Your Partner
Advance sling
A small “sling” made of synthetic
mesh is placed inside the body
through three small incisions.
The Satisfying Solution for You and Your Partner
Artificial Urinary Sphincter
(AUS)
Over 100,000 implanted since
1972
The Gold Standard for
treatment of moderate to
severe incontinence
•
Minimally invasive
•
92% of patients would have
the device placed again
•
96% of patients would
recommend it to a friend
•
Device is placed completely
in the body, providing
simple, discreet control
Litwiller SE, et al. Post-prostatectomy incontinence and the artificial urinary sphincter; a long-term study of patient satisfaction and criteria for success.
J of Urol 1996; 156:1975-1980.
The Satisfying Solution for You and Your Partner
The Satisfying Solution for You and Your Partner
Three – Piece Inflatable
Penile Implant
Advantages
• Acts and feels more like a
natural erection
• Expands the girth of the penis
• More firm and full than other
implants
• Feels softer and more flaccid
when deflated
The Satisfying Solution for You and Your Partner
My Experience with a
Penile Implant
• Totally concealed
• Easy to operate
• Feels natural
• A life-changing solution
• Regret waiting 2 years
2
CC Carson, JJ Mulcahy, FE Govier, Efficacy, safety and patient satisfaction outcomes of the AMS 700CX inflatable penile prosthesis:
Results of a long-term multi-center study. AMS 700CX Study Group. J. Urol. 2000 Aug; 164 (2): 376-80.
The Satisfying Solution for You and Your Partner
Talk To Your Partner!
• Talk about what you both want and
need
• Discuss your treatment options
together with your urologist
• Talk to others with the same problem
The Satisfying Solution for You and Your Partner
Questions &
Answers